Provider Demographics
NPI:1558650291
Name:HAEBERLE, MARK TYE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TYE
Last Name:HAEBERLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950132
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0132
Mailing Address - Country:US
Mailing Address - Phone:888-980-8992
Mailing Address - Fax:
Practice Address - Street 1:3810 SPRINGHURST BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-583-1749
Practice Address - Fax:502-329-8184
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47890207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100215390Medicaid
KY7100215390Medicaid